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Tuesday, June 14, 2011

Should Advair be discontinuued while patient on systemic corticosteroids?

Your humble question A pt presented the ED with a mild asthma attack. She takes Albuterol PRN and Advair BID at home. The nurse practitioner ordered Duoneb Q4 and Perforomist Q12. At our our institution we supplement Symbicort for Advair so I naturally approached the NP wanting to try to keep the pt on something as close to her home meds as I could.

The NP said he did not want to "double" her up on corticosteroids since he also ordered her on oral corticosteroids.

So I guess my question is do you have any references about pt's inhaled long term controller meds like Advair and Symbicort being discontinued if they are also talking oral or injected Corticosteroids? The NP couldn't provide any references to why this his "preference" to do it this way.

My Humble AnswerThe amount of steroid in Advair is the equivalent of about 5mg of prednisone, and is essentially irrelevant when you're talking about systemic corticosteroids.  Another thing to note is Advair also has Serevent in it, of which the asthmatic should not stop taking when admitted to the hospital -- especially when admitted to the hospital.  A third factor is that studies show very few asthmatics are compliant with their home asthma medicine regime, so if you have a patient in the habit of taking his Adviar as prescribed, it should not be stopped while in the hospital.

So I wouldn't say there is a policy per se where I work, yet most of our doctors continue this medicine while a patient is admitted.  If it's not ordered, we RTs usually do as you did and recommend it.  While I'm not aware of any references that says as much, I think a little common sense should prevail here. 

However, in your NPs defence, I've noticed that many doctors like to use Ventolin as a preventative medicine instead of using Serevent.  So, so long as your patient is getting Q4 Ventolin and systemic steroids, there really is no medical need to continue Advair in the short term.  I don't particularly care for this technique as it results in many unnecessary treatments, yet I find it's also quite common. 

If you learn anything more, or find a reference, or your NP provides you with some sort of reference to prove her right, let me know so I can share it with my readers. If any of my readers have any further ideas, opinions, or references regarding this topic, please inquire within.



Jerry said...

If the NP doesn't like doubling up on meds, why is he continuing to give the patient two beta agonists?

Anonymous said...

I have never discontinued my Advair 500-2 puffs BID when I'm on increased Pred (40mg). And I'm on this dose of Advair permanently as well as a baseline Pred dose of 10mg. I've never even had it that my Advair was discontinued when in hospital and on IV solu-medrol. It seems that if I can still function enough to inhale the Advair, then I am still to take it!
I guess our two countries differ then! (I'm in the UK)